Orthopaedic clinical officer program in Malawi: a model for providing orthopaedic care.
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ABSTRACT:
SUBMITTER: Mkandawire N
PROVIDER: S-EPMC2584281 | biostudies-other | 2008 Oct
REPOSITORIES: biostudies-other
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Project description:BackgroundDespite tremendous progress in antiretroviral therapy (ART) and access to ART, many patients have advanced human immunodeficiency virus (HIV) disease (AHD). Patients on AHD, whether initiating ART or providing care after disengagement, have an increased risk of morbidity and mortality. The Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) launched an enhanced care package using a hub-and-spoke model to optimize AHD care in Malawi. This model improves supply availability and appropriate linkage to care. We utilized a hub-and-spoke model to share health facility challenges and recommendations on the AHD package for screening and diagnosis, prophylaxis, treatment, and adherence support.MethodsThis qualitative study assessed the facility-level experiences of healthcare workers (HCWs) and lay cadres (LCs) providing AHD services to patients through an intervention package. The study population included HCWs and LCs supporting HIV care at four intervention sites. Eligible study participants were recruited by trained Research Assistants with support from the health facility nurse to identify those most involved in supporting patients with AHD. A total of 32 in-depth interviews were conducted. Thematic content analysis identified recurrent themes and patterns across participants' responses.ResultsWhile HCWs and LCs stated that most medications are often available at both hub and spoke sites, they reported that there are sometimes limited supplies and equipment to run samples and tests necessary to provide AHD care. More than half of the HCWs stated that AHD training sufficiently prepared them to handle AHD patients at both the hub and spoke levels. HCWs and LCs reported weaknesses in the patient referral system within the hub-and-spoke model in providing a linkage of care to facilities, specifically improper referral documentation, incorrect labeling of samples, and inconsistent availability of transportation. While HCWs felt that AHD registers were time-consuming, they remained motivated as they thought they provided better patient services.ConclusionsThese findings highlight the importance of offering comprehensive AHD services. The enhanced AHD program addressed weaknesses in service delivery through decentralization and provided services through a hub-and-spoke model, improved supply availability, and strengthened linkage to care. Additionally, addressing the recommendations of service providers and patients is essential to improve the health and survival of patients with AHD.
| S-EPMC10897989 | biostudies-literature
Project description:BackgroundThe well-documented shortages of health care workers (HCWs) in sub-Saharan Africa are further intensified by the increased human resource needs of expanding HIV treatment programs. Burnout is a syndrome of emotional exhaustion (EE), depersonalization (DP), and a sense of low personal accomplishment (PA). HCWs' burnout can negatively impact the delivery of health services. Our main objective was to examine the prevalence of burnout amongst HCWs in Malawi and explore its relationship to self-reported suboptimal patient care.MethodsA cross-sectional study among HCWs providing HIV care in 89 facilities, across eight districts in Malawi was conducted. Burnout was measured using the Maslach Burnout Inventory defined as scores in the mid-high range on the EE or DP subscales. Nine questions adapted for this study assessed self-reported suboptimal patient care. Surveys were administered anonymously and included socio-demographic and work-related questions. Validated questionnaires assessed depression and at-risk alcohol use. Chi-square test or two-sample t-test was used to explore associations between variables and self-reported suboptimal patient care. Bivariate analyses identified candidate variables (p < 0.2). Final regression models included variables with significant main effects.ResultsOf 520 HCWs, 62% met criteria for burnout. In the three dimensions of burnout, 55% reported moderate-high EE, 31% moderate-high DP, and 46% low-moderate PA. The majority (89%) reported engaging in suboptimal patient care/attitudes including making mistakes in treatment not due to lack of knowledge/experience (52%), shouting at patients (45%), and not performing diagnostic tests due to a desire to finish quickly (35%). In multivariate analysis, only burnout remained associated with self-reported suboptimal patient care (OR 3.22, [CI 2.11 to 4.90]; p<0.0001).ConclusionBurnout was common among HCWs providing HIV care and was associated with self-reported suboptimal patient care practices/attitudes. Research is needed to understand factors that contribute to and protect against burnout and that inform the development of strategies to reduce burnout.
| S-EPMC5821338 | biostudies-literature
Project description:In 2015, the Centers for Medicare & Medicaid Services (CMS) implemented a new benefit called chronic care management (CCM). A recent CMS-commissioned study of the program showed that CCM is effective in increasing advance care planning and decreasing overall costs. Despite positive effects on care planning, utilization, and cost, the CCM program remains underutilized. The authors sought to develop a platform to enable scale of the CCM program, and to report outcomes associated with its use. A technology and integrated clinical staff platform was built to enable a scalable, evidence-based implementation of the Medicare CCM program. The model created care management data elements that were used to flag clinical and utilization risks such as falls, mortality, hospitalization and polypharmacy. In 2018, CCM support was provided for 26,500 patients. Logistic regression analyses were used to identify risk factors associated with hospitalization. The cohort experienced 2679 hospitalizations (184 admissions per 1000 patient months per year). Among patients residing in non-nursing home settings, a higher Gagne mortality risk was associated with a 32 times greater chance of being hospitalized. Other positive predictors of hospitalization included being a nursing home resident and being ambulatory without assistance. Negative predictors of hospitalization included being flagged as having a high hospitalization risk, and scoring in the low-risk category for falls or polypharmacy. This CCM model is a scalable method of supporting care management for people with multiple chronic conditions, and can help identify risk factors for hospitalization.
| S-EPMC7074917 | biostudies-literature
Project description:BackgroundThree district hospitals in Malawi that provide essential surgery, which for many patients can be lifesaving or prevent disability, formed the setting of this costing study.MethodsAll resources used at district hospitals for the delivery of surgery were identified and quantified. The hospital departments were divided into three categories of cost centres-the final cost centre, intermediate and ancillary cost centres. All costs of human resources, buildings, equipment, medical and non-medical supplies and utilities were quantified and allocated to surgery through step-down accounting.ResultsThe total cost of surgery, including post-operative care, ranged from US$ 329,000 per year to more than twice that amount at one of the hospitals. At two hospitals, it represented 16-17% of the total cost of running the hospital. The main cost drivers of surgery were transport and inpatient services, including catering. The cost of a C-section ranged from $ 164 to 638 that of a hernia repair from $ 137 to 598. Evacuations from uterus were cheapest mainly because of the shorter duration of patient stay.ConclusionLow bed occupancy rates and utilisation rates of the operating theatres suggest overcapacity but may also indicate a potential to scale up surgery. This may be achieved by adding surgical staff, although there may be rate-limiting steps, such as demand for surgery in the community or capacity to provide anaesthesia. If a scale-up of surgery cannot be realised, hospital managers may be forced to reduce the number of beds, reorganise wards and/or reallocate staff to achieve better economies of scale.
| S-EPMC5740194 | biostudies-literature
Project description:ImportanceInjuries cause 30% more deaths than HIV, TB and malaria combined, and a prospective fracture care registry was established to investigate the fracture burden and treatment in Malawi to inform evidence-based improvements.ObjectiveTo use the analysis of prospectively-collected fracture data to develop evidence-based strategies to improve fracture care in Malawi and other similar settings.DesignMulticentre prospective registry study.SettingTwo large referral centres and two district hospitals in Malawi.ParticipantsAll patients with a fracture (confirmed by radiographs)-including patients with multiple fractures-were eligible to be included in the registry.ExposureAll fractures that presented to two urban central and two rural district hospitals in Malawi over a 3.5-year period (September 2016 to March 2020).Main outcome(s) and measure(s)Demographics, characteristics of injuries, and treatment outcomes were collected on all eligible participants.ResultsBetween September 2016 and March 2020, 23,734 patients were enrolled with a median age of 15 years (interquartile range: 10-35 years); 68.7% were male. The most common injuries were radius/ulna fractures (n = 8,682, 36.8%), tibia/fibula fractures (n = 4,036, 17.0%), humerus fractures (n = 3,527, 14.9%) and femoral fractures (n = 2,355, 9.9%). The majority of fractures (n = 21,729, 91.6%) were treated by orthopaedic clinical officers; 88% (20,885/2,849) of fractures were treated non-operatively, and 62.7% were treated and sent home on the same day. Open fractures (OR:53.19, CI:39.68-72.09), distal femoral fractures (OR:2.59, CI:1.78-3.78), patella (OR:10.31, CI:7.04-15.07), supracondylar humeral fractures (OR:3.10, CI:2.38-4.05), ankle fractures (OR:2.97, CI:2.26-3.92) and tibial plateau fractures (OR:2.08, CI:1.47-2.95) were more likely to be treated operatively compared to distal radius fractures.Conclusions and relevanceThe current model of fracture care in Malawi is such that trained orthopaedic surgeons manage fractures operatively in urban referral centres whereas orthopaedic clinical officers mainly manage fractures non-operatively in both district and referral centres. We recommend that orthopaedic surgeons should supervise orthopaedic clinical officers to manage non operative injuries in central and district hospitals. There is need for further studies to assess the clinical and patient reported outcomes of these fracture cases, managed both operatively and non-operatively.
| S-EPMC8336825 | biostudies-literature
Project description:Behçet's syndrome (BS) is a multisystem vasculitis that presents with a variety of mucocutaneous manifestations such as oral and genital ulcers, papulopustular lesions and erythema nodosum as well as ocular, vascular, gastrointestinal and nervous system involvement. Although it occurs worldwide, it is especially prevalent in the Far East and around the Mediterranean Sea. Male gender and younger age at disease onset are associated with a more severe disease course. The management of BS depends on the severity of symptoms. If untreated, morbidity and mortality are considerably high in patients with major organ involvement. Multidisciplinary patient care is essential for the management of BS, as it is for other multisystem diseases. Rheumatologists, dermatologists, ophthalmologists, neurologists, cardiovascular surgeons and gastroenterologists are members of the multidisciplinary team. In this study, we reviewed the epidemiology, etiology, diagnostic criteria sets, clinical findings and treatment of BS and highlighted the importance of the multidisciplinary team in the management of BS.
| S-EPMC5565245 | biostudies-other
Project description:BACKGROUND:In Malawi, early retention in HIV care remains challenging. Depression is strongly associated with reduced anti-retroviral therapy (ART) adherence and viral suppression. Appropriate depression care for people initiating ART is likely to be supportive of early and continued engagement in the HIV care continuum. This paper aims to provide an overview of a task-shifting program that integrates depression screening and treatment into HIV care and the strategy used to evaluate this program, describes the implementation process, and discusses key challenges and lessons learned in the first phase of program implementation. METHODS:We are implementing a program integrating depression screening and treatment into HIV care initiation at two clinics in Lilongwe District, Malawi. The program's effect on patients' depression and HIV outcomes will be evaluated using a multiple baseline pre-post study. In this manuscript, we draw from our experiences as program implementers and some of the quantitative data to describe the process of implementation and key lessons learned. RESULTS:We successfully implemented the screening phase of this program at both clinics; 88.3 and 93.2% of newly diagnosed patients have been screened for depression at each clinic respectively. 25% of enrolled patients reported symptoms of mild-to-severe depression and only 6% reported symptoms of moderate-to-severe depression. Key lessons learned from the process show the importance of utilizing existing processes and infrastructure and focusing on iterative and collaborative learning. We continued to face challenges around establishing a sense of program ownership among providers, developing capacity to diagnose and manage depression, and ensuring the availability of appropriate medication. Our efforts to address these challenges provide insight into the technical and managerial support needed to prepare for, roll out, and sustain integrated models of mental health and HIV care. CONCLUSIONS:This activity demonstrates how a depression screening program can successfully be integrated into HIV care within the public health system in Malawi. While this program focuses on integrating depression management into HIV care, most of the lessons learned could apply to integration of mental health into any non-psychiatric specialist setting. TRIAL REGISTRATION:ClinicalTrials.gov ID [ NCT03555669 ]. Retrospectively registered on 13 June 2018.
| S-EPMC6069990 | biostudies-literature
Project description:OBJECTIVE: To describe patient antiretroviral therapy (cART) outcomes associated with intensive decentralization of services in a rural HIV program in Malawi. METHODS: Longitudinal analysis of data from HIV-infected patients starting cART between August 2001 and December 2008 and of a cross-sectional immunovirological assessment conducted 12 (±2) months after therapy start. One-year mortality, lost to follow-up, and attrition (deaths and lost to follow-up) rates were estimated with exact Poisson 95% confidence intervals (CI) by type of care delivery and year of initiation. Association of virological suppression (<50 copies/mL) and immunological success (CD4 gain ?100 cells/µL), with type of care was investigated using multiple logistic regression. RESULTS: During the study period, 4322 cART patients received centralized care and 11,090 decentralized care. At therapy start, patients treated in decentralized health facilities had higher median CD4 count levels (167 vs. 130 cell/µL, P<0.0001) than other patients. Two years after cART start, program attrition was lower in decentralized than centralized facilities (9.9 per 100 person-years, 95% CI: 9.5-10.4 vs. 20.8 per 100 person-years, 95% CI: 19.7-22.0). One year after treatment start, differences in immunological success (adjusted OR=1.23, 95% CI: 0.83-1.83), and viral suppression (adjusted OR=0.80, 95% CI: 0.56-1.14) between patients followed at centralized and decentralized facilities were not statistically significant. CONCLUSIONS: In rural Malawi, 1- and 2-year program attrition was lower in decentralized than in centralized health facilities and no statistically significant differences in one-year immunovirological outcomes were observed between the two health care levels. Longer follow-up is needed to confirm these results.
| S-EPMC3471893 | biostudies-other
Project description:OBJECTIVE:Our aim was to explore how the care managers put the complex care manager task into practice and how they perceived their task, which was to facilitate effective, person-centred treatment for stress-related disorder concordant with evidence-based guidelines in primary care. DESIGN:This was a qualitative study using examination reports from the course for care managers. Systematic text condensation according to Malterud was used for the analysis. SETTING:Primary health care centres. SUBJECT:Twenty-eight newly educated care managers in primary health care participated in the study. The median age was 50 (31-68) years. Twenty-seven were women and one was a man. Twenty-one were employed as nurses and seven as counsellors. RESULTS:The informants perceived the role as care manager as meaningful but at times complicated. To participate in teams and to work closely with the general practitioner was experienced as important. The co-ordinating function was emphasised as especially important, as well as the increased continuity in care. The dual role as care manager and counsellor was sometimes experienced as problematic. CONCLUSION:The informants took advantage of the knowledge they had attained during the course. They perceived themselves as being a bridge between patients and other professionals. The result of having dual roles at the primary health care centre unexpectedly revealed difficulties for some professionals. The nurses seemed more familiar with the new way of working.
| S-EPMC6850534 | biostudies-literature
Project description:The ageing of society is leading to significant reforms in long-term care policy and systems in many European countries. The cutbacks in professional care are increasing demand for informal care considerably, from both kin and non-kin. At the same time, demographic and societal developments such as changing family structures and later retirement may limit the supply of informal care. This raises the question as to whether the volume of informal care (in people) will increase in the years ahead. This paper aims to provide a theoretical answer to this question in two steps. First, based on different care models and empirical literature, we develop a behavioural model on individual caregiving, the Informal Care Model. The model states that, in response to the care recipient's need for care, the intention to provide care is based on general attitudes, quality of the relationship, normative beliefs, and perceived barriers. Whether one actually provides care also depends on the care potential of the social context, being the family, the social network, and the community. Second, we discuss how current policy and societal developments may negatively or positively impact on these mechanisms underlying the provision of informal care. Given the increased need for care among home-dwelling individuals, the model suggests that more people will take up the caregiver role in the years ahead contributing to larger and more diverse care networks. It is concluded that long-term informal care provision is a complex phenomenon including multiple actors in various contexts. More research is needed to test the Informal Care Model empirically, preferably using information on care recipients, informal caregivers and community care in a dynamic design and in different countries. Such information will increase insight in the developments in informal care provision in retrenching welfare states.
| S-EPMC4992501 | biostudies-other